Surg Today (2007) 37:622–625DOI 10.1007/s00595-006-3471-7

Reprint requests to: A.E. Lasheen, Hay Elsalam, El-Roda El-Sharifa Street, No. 14, Zagazig City, EgyptReceived: March 18, 2006 / Accepted: June 15, 2006

How to Do It

Implantation of a Skin Graft Tube to Create a Saphenoperitoneal Shunt for Refractory Ascites

Ahmed E. Lasheen1,2, Awni Elzeftawy1, Samir Ibrahim1, Mohammed Attia1, and Mohammed Emam1

1 Departments of General Surgery and Tropical Medicine, Faculty of Medicine, Zagazig University, Zagazig City 44519, Egypt2 Hay Elsalam, El-Roda El-Sharifa Street, No. 14, Zagazig City, Egypt

AbstractPurpose. We evaluated the effectiveness of placing a skin tube in the subcutaneous plane to manage refrac-tory ascites by draining the ascitic fl uid from the perito-neal cavity into the long saphenous vein.Methods. Twenty patients with refractory ascites under-went this technique which was performed in two stages. In the fi rst stage, a thin piece of partial thickness skin graft was rolled into a tube and implanted in the subcu-taneous plane of the lower abdomen and the upper thigh near and parallel to the upper segment of the long saphenous vein. In the second stage, which was done 3 months later, we anastomosed the upper end of the skin tube to the peritoneal cavity and the lower end of the skin tube to the long saphenous vein. The follow-up period was 4 years.Results. There was no mortality. The complications consisted of hematoma formation in two patients, wound infection in three, and ascitic fl uid leakage from the upper anastomosis in three. All these complications were managed conservatively.Conclusion. These fi ndings show that creating a saphe-noperitoneal shunt with a skin graft tube interposition is a novel, safe, and cost-effective technique of resolving the problem of refractory ascites.

Key words Skin graft · Saphenoperitoneal · Shunt · Ascites

Introduction

Intractable ascites are ascites that do not respond to medical treatment. They account for 5%–10% of the

cases of ascites.1 The symptoms of respiratory embar-rassment with hypoxia and impairment of locomotion may be the most debilitating aspects of the disease pro-cess.2 The peritoneovenous shunt (PVS) plays a major role in surgery for intractable ascites.3–5 A number of drainage systems have been developed over the course of time, including the Le Veen, Denver, and direct sa-phenoperitoneal shunts.6,7 We conducted this study to evaluate the effectiveness of using a thin partial thick-ness skin graft tube to drain ascitic fl uid from the peri-toneal cavity into the peripheral circulation through the upper segment of the long saphenous vein for the treatment of refractory ascites.

Patients and Methods

Twenty patients suffering from intractable cirrhotic as-cites were the subjects of this study. There were 13 men and 7 women, with a mean age of 51.7 years (35–63 years). All patients underwent clinical examinations, which included the daily measurement of abdominal girth, body weight, and urine output, and full laboratory investigations, as well as cytology and culture of the as-citic fl uid. Patients with suspected or proven pathologi-cal causes of ascites other than cirrhosis, those with possible non-sterile ascitic fl uid, and those with a very high bilirubin level were excluded from study. The Child–Pugh–Turcott classifi cation of this group of pa-tients ranged from 7 to 12. We confi rmed by duplex scanning that the saphenofemoral valve was competent in all patients.

Technique

This technique was done under local anesthesia and in two stages. In stage 1 (skin tube formation), a thin par-tial thickness skin graft, about 30 cm long and 3 cm wide,

A.E. Lasheen et al.: Skin Graft Tube for a Saphenoperitoneal Shunt 623

was taken from the thigh. We created a tube from this skin graft by rolling it over an 18-20F lax tube. The skin surface of the graft was directed inside toward the lax tube and the free edges were sutured with 6-0 catgut running sutures. Next, we implanted the skin graft tube with the lax tube in the subcutaneous plane of the lower abdomen and upper thigh, using a long, sharp metal tube. We placed the upper end of the skin tube close to the peritoneal cavity and the lower end of the skin tube as close as possible, and parallel to, the upper segment of the long saphenous vein. The upper and lower ends of the skin tube were fi xed to the skin surface of the body with sutures and the lax tube was left inside the skin tube for 10 days, until the graft had taken. We

washed out the lax tube with normal saline during this period daily. For the next 3 months, we observed the implanted skin tube for patency and acceptance by pass-ing a special probe and injecting normal saline regularly through both its upper and lower openings. Stenosis was easily corrected by regular dilatation with a dilator or balloon infl ation (Fig. 1a–d).

In stage 2 (skin tube anastomosis), we made two incisions, one around the upper opening and the other around the lower opening of the skin tube, and dissected a 2-cm segment from its upper and lower ends free from the surrounding tissues. We anastomosed the upper end of the skin tube to the peritoneal cavity through the muscles splitting of the anterior abdominal

Fig. 1. a Rolling the skin graft into a tube around a lax tube. b The skin graft tube is implanted in the subcutaneous plane by inserting a sharp metal tube into the abdominal wall and thigh. c An anastomosis is done between the upper end of the

skin tube and the peritoneal cavity. d An anastomosis is done between the lower end of the skin tube and the upper segment of the long saphenous vein

a

b

dc

624 A.E. Lasheen et al.: Skin Graft Tube for a Saphenoperitoneal Shunt

wall, using a 6-0 polypropylene suture. Then, we dis-sected the proximal 5 cm of the long saphenous vein and occluded all of its tributaries, and the distal end of this segment, using a continuous polypropylene ligature. Fi-nally, we performed an end-to-side anastomosis be-tween the lower end of the skin tube and this segment of the long saphenous vein using a 6-0 polypropylene suture. The pressure of ascitic fl uid on the suture line was reduced by placing the patient in the Trendelen-burg position and aspirating ascitic fl uid, after giving two or three units of human albumin intravenously a few hours preoperatively. The top and bottom wounds were closed in layers without a drain, and normal wound care was done daily. We continued to measure abdomi-nal girth, body weight, and urine output daily with regu-lar heart and chest examinations. The postoperative laboratory tests included complete blood count, liver function tests, and coagulation profi le. A duplex exami-nation was done to assess the patency of the skin tube and the ascitic fl ow through it. The patient was exam-ined while sitting and standing using a Valsalva maneu-ver. The saphenofemoral valve function was also assessed. The follow-up period was 4 years.

Results

The skin graft strip must consist of one complete piece and be thin enough to take well and limit squamous cell debris. Initially, we experienced some diffi culty during implanting the skin tube, but these problems were re-solved by using the sharp metal tube. There was no mortality associated with this technique. Clinical evalu-ation of the patients confi rmed a decrease in the amount of ascitic fl uid, a reduction in body weight and abdomi-nal girth, an increase in urine output, and improved respiration and nutrition, especially in the fi rst 3 months, and these improvements were maintained. Laboratory assessment showed no signifi cant changes pre- to post-operatively. The duplex examination revealed patency of the skin tube with low fl ow in the sitting position, which increased in the standing position, and during the Valsalva maneuver (Fig. 2). Five (25%) patients died of liver failure during the fi rst year of follow-up. The com-plications recorded were wound hematoma in two (10%) patients, which resolved with suitable antibiotic therapy and hot foments; wound infections in three (15%) patients, which were treated effectively by daily dressings and systemic antibiotics; and ascitic fl uid leak-age from the upper anastomosis with the peritoneum in three (15%) patients, which was managed conserva-tively by decreasing the tension on the anastomotic line with a high dose of a diuretic agents, salt intake restric-tion, intravenous human albumin, and a compression dressing over the leakage site. The ascitic fl uid leakage

decreased gradually and stopped completely within 3 weeks. The function of this skin tube as a shunt depends on the success of stage 1 (skin tube formation). If this stage produces a well-formed patent skin tube with a suitable diameter, it will remain patent in spite of these complications.

Discussion

Intractable ascites interferes with respiration, mobility, and nutrition.6 Many methods have been designed to drain ascitic fl uid, including omentopexy, overfl ow into the renal pelvis, drainage through the bladder or into the subcutis, ileoentectropy,8–10 and PVS by Le Veen and Denver, and direct saphenoperitoneal shunts.6,7 Physiopathologically, the PVS increases plasma volume, fi lling pressure of the right side of the heart, cardiac output, and renal perfusion, promoting diuresis and the onset of natriuresis, with the reversed hormonal modi-fi cations usually associated with refractory ascites such as increased plasma aldosterone, renin antidiuretic fac-tor, and norepinephrine. Thus, the PVS restores and sustains normal blood volume, thereby correcting hypo-volemia. Moreover, by preventing albumin sequestra-tion and relieving abdominal distension, the PVS helps to improve the nutritional status of the patients.10,11 Ac-cording to previous reports, the complications of a PVS included infection related to the shunt tubes, superior vena cava thrombosis, disseminated intravascular coag-ulation, and shunt malfunction, all of which occurred at high rates of up to 50%.7,11 Thus, we tried to prevent these complications. First, using an autogenous skin tube instead of a silastic tube decreased the incidence of infection and there was no cost. Second, the drainage of ascitic fl uid into peripheral venous circulation instead of into the central venous circulation decreased coagu-lopathy. Third, the competent saphenofemoral valve and the thin partial thickness skin tube graft prevented sweat and sebaceous gland sections, thereby maintain-ing good drainage without obstruction.

In conclusion, we think that using an implanted par-tial thickness skin tube as a saphenoperitoneal shunt is a simple and cost-effective way of treating intractable

Fig. 2. Duplex scan showed patency of the skin graft tube

A.E. Lasheen et al.: Skin Graft Tube for a Saphenoperitoneal Shunt 625

ascites effectively, with a low risk of major complica-tions. However, further studies are needed to determine whether there are any long-term complications or his-tological changes in this skin tube after it has been in place for an extended period.

References

1. Arroyo V, Gines P, Gerbes AL. Defi nition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. Hepa-tology 1996;23:164–76.

2. Garcia N, Sanyal AJ. Ascites. Curr Treat Options Gastroenterol 2001;4:527–37.

3. Le Veen HH, Wapnick S, Diaz C, Grosberg S, Kinney M. Ascites: its correction by peritoneovenous shunting. Curr Probl Surg 1979;16:1–61.

4. Hillaire S, Labianca M, Borgonovo G. Peritoneovenous shunting of intractable ascites in patients with cirrhosis: improving results and predictive factors of failure. Surgery 1993;113:373–9.

5. Zervos EE, Rosemurgy AS. Management of medically refractory ascites. Am J Surg 2001;181:256–64.

6. Roussel JG, Kroon BB, Hart GA. The Denver type for perito-neovenous shunting of malignant ascites. Surg Gynecol Obstet 1986;162:235–40.

7. Utikal P, Drac P, Bachleda P, Klein J, Kral V, Hrabalova M. Peritoneovenous shunting modifi cation with the use of long saphenous shunt. Biomed Paper 2004;149:89–90.

8. Cook HH. Omentopexy as an aid in treating cases of cirrhosis with ascites. J Christ Med Assoc India 1953;28:142–4.

9. Mulvany D. Vesico-coelomic drainage for the relief of ascites. Lancet 1955;2:747–9.

10. Neumann CG, Adie GC, Hinton JW. The absorption of ascitic fl uid by means of ileoentectropy in patients with advanced cir-rhosis. Ann Surg 1957;146:700–5.

11. Tueche SG, Pector JC. Peritoneovenous shunt in malignant asci-tes. Hepatogastroenterology 2000;47:1322–4.